Community Alliance for the Ethical Treatment of Youth (CAFETY)

Policy paper adopted by American Association of Children's Residential Centers (AACRC), written in Collaboration with CAFETY and YouthMOVE.

Redefining Residential: Youth Guided Treatment
Adopted April, 2010

Preface from Youth Advocates Redefining Residential:

Youth-Guided Treatment is the outgrowth of a partnership between AACRC, CAFETY (Community Alliance for the Ethical Treatment of Youth; www.cafety.org), and YouthMOVE (Youth Motivating Others through Voices of Experience; www.youthmove.us). We are excited to have been asked to collaborate with AACRC in creating this document, as the association continues a series of policy papers that highlight new trends and promising practices in residential care. The collaborative work and open dialogue that generated this document are essential elements of “youth-guided treatment” and a good example of what ideally would happen on a daily basis in partnering with youth. We expect this dialogue to continue as we work to achieve redefinition of residential and true system transformation, and hope that this paper helps organizations across the country move in this direction.

This is the 7th in a series of papers from the American Association of Children’s Residential Centers regarding key program and policy issues facing the field of residential treatment. AACRC is the longest standing national association focused exclusively on the needs of the children who require residential treatment and their families. Over the past several years AACRC has engaged with national policy makers, family members, youth, and its membership in an effort to redefine the shape and scope of residential treatment as an intervention for youth and their families.

Over the past decade the importance of engaging youth in guiding their own treatment and helping shape the system of services and supports has become increasingly evident. Youth have become involved in national, state, and local policy arenas and have developed organized youth driven advocacy groups. Through these activities they have identified effective practices to meaningfully involve youth in improving outcomes in various service settings, including residential treatment. AACRC featured youth guided treatment as the keynote theme of its 2009 conference, which included a youth caucus that presented recommendations to the membership.

This paper emanates from those discussions. It identifies concerns youth have had with the traditional provision of residential treatment, offers a definition of youth-guided care, examines issues related to implementing youth guided care in residential treatment, and offers specific ideas and steps organizations and the field can consider as we strive to continually improve our work.

Youth Concerns

Young people who have been placed in residential settings recognize that residential providers typically operate with the best interests of the young people they work with at heart. However youth are concerned that providers and staff in residential programs are often not open to the idea that their approaches and interventions may not be ideal, even in the most extreme situations when the measures being used upon the young people in their care are abusive. While such cases may not typify the field of residential treatment, they do highlight legitimate and serious practice concerns.

Residential providers often hear the praises of alumni for the help they received. Less often do the criticisms of youth past and present get the same attention. These youth express a variety of concerns that they feel residential providers did not and do not hear. For example:

• Youth have often experienced staff attitudes and approaches that are patronizing and infer that the youth in care do not understand themselves as well as, or better than, the adults; this finds expression in decision making that not only doesn’t include the youth but dismisses the possibility that they might have valuable ideas, perhaps even better than those of the staff.
• Young people often have not experienced meaningful opportunities to discuss or question placement or to be engaged in formulating and carrying out their own treatment plans. They find themselves left with the choice of complying with a set of provisions into which they had no input or complaining, which could jeopardize their privileges or movement toward discharge. They ask that there be “nothing about us without us”.
• Point and level systems used in many residential programs are arbitrary and not responsive to their individual needs or relevant to real-life situations they will be in after discharge.
• Behavior that in many settings would be seen as “normal” is viewed as pathological.
• Staff responses to behavior are at times coercive and induce stress and fear.
• Communication with families and friends is seen by staff as a barrier to treatment.
• Treatment philosophies and approaches don’t always take the values of individual youth nor those of the youth culture into serious consideration.

Residential programs have taken notable steps toward addressing these concerns and implementing youth guided care. While it is probably safe to say that an evolutionary process in this direction has been occurring over the past decade, old habits, especially mental habits, die hard. So despite the evolution that has occurred in the field, there still tends to be collective mindsets in the system and within individual organizations that diminish the importance of meaningful youth involvement. The problem is exacerbated by residential’s typical role as the placement of last resort. Youth entering residential may feel beaten down, cynical, and untrusting due to their experiences thus far, and not receptive to good-faith efforts that may occur to encourage them to participate in their own treatment. Implementing youth-guided care can help mitigate or even eliminate this circumstance.

What is Youth-Guided Care?

Youth-guided care has been defined as follows:

“Youth guided means that young people have the right to be empowered, educated, and given a decision-making role in the care of their own lives as well as the policies and procedures governing care in their organizations and/or communities. This includes giving young people a sustainable voice, being listened to, and the focus should be towards creating a safe environment enabling a young person to gain self-sustainability in accordance to the cultures and beliefs they abide by. Further through the eyes of a youth-guided approach we are aware that there is a continuum of power that should be given to young people based on their understanding and maturity in this strength based change process. Youth guided also means that this process should be fun and worthwhile.” (www.samhsa.hhs.gov)

Youth-guided care represents a mindset that can be adopted regardless of the age of the child or youth, one that encompasses consideration and appreciation of each individual as well as awareness of and respect for age, culture, language, and developmental level. It is the first step in the spectrum of youth involvement, one that also extends to youth-directed and youth-driven services.

Implementing Youth-Guided Care

So what would youth-guided care in a residential treatment program look like? A key factor is creating a culture at both the care and organizational levels that embraces the importance of engaging the youth in shared decision-making and problem solving. At the care level, it may be helpful to contrast examples of youth-guided care using the three phases outlined in the Matrix of Performance Guidelines in the Building Bridges Initiative (www.buildingbridges4youth.org), with what youth often experience in “traditional” residential treatment.

Entry phase –Most often the decision to place a young person in a residential program is made without any conversation with the youth. Although the reasons for the placement decision may be seemingly obvious to all involved, the child/youth is not given the respect of being provided with information about where they are going or specifics about the program. In youth-guided practice:

• the young person is an active participant in the evaluation process, informed with understandable and complete information about all effective treatment options and available alternatives, and engaged in decision-making that respects and considers his/her perspective;
• the young person is paired with a peer advocate (a young person who has experience in a residential program themselves) so that the young person can have the necessary support to feel comfortable speaking their mind;
• intake and engagement protocols solicit active participation by the child and peer advocates.

Treatment phase – The degree to which youth are engaged in determining their own course of treatment is variable across agencies, but often they are passive recipients, with adults setting their goals set for them based on the reasons for their placement. This has some logic, as whoever placed the child may require specific attention to remediation of specific deficits. Nonetheless treatment progress and outcome improve with a strengths-based approach in which:

• the client is able to identify what they want to accomplish during their stay and to voice their thoughts about the best way to achieve their goals;
• disagreements are addressed through problem-solving dialogue.

At the very least engaging the youth in this way conveys respect, which over time facilitates the development of self-determination skills that will serve the individual well as they get older. This positive impact of youth-guided practice occurs regardless of the child’s age, although of course the nature of the involvement will be different based on the youth’s age and developmental level.

In many places treatment is still based on a “program”, with stages, levels, or other structured elements that are not truly individualized. In youth guided treatment planning:

• staff responses to specific circumstances are individualized, not driven by a set of group-wide guidelines or “default” consequences or levels that may not fit the situation and may be experienced as unfair and arbitrary;
• each youth and family is engaged in determining all aspects of the individualized plan including what responses to his or her behavior will likely be most effective, the timing and purpose of visits, skill building activities on campus and in the community; etc.
• programming uses the peer group in conjunction with staff to identify community activities and skill building opportunities likely to be beneficial;
• staff are trained to focus on strengths and on how to resolve disagreements such that youth concerns are heard and responded to without dismissing adult concerns.

Transition phase – In traditional residential settings graduation from a program is often based on the completion of a step or level program, not necessarily on an ongoing process of evaluating whether the youth is ready to return to the community. Youth at times feel as if they’ve been dropped into a chasm, without having had a chance to work with residential staff, their families, or community providers to plan a careful transition into their next living situation. While it is often required that discharge planning starts at intake, this doesn’t always occur, and youth are not integrally involved in designing their discharge plan. In youth-guided care:

• youth are regularly engaged in conversation regarding the discharge plan and in identifying the services that they feel would benefit them;
• youth are afforded choices to extend or reinitiate services that may have been helpful during the residential treatment phase once they return home.

Beyond, but related to, these phase-specific provisions, it is critical that organizations create as normative an environment for young people in their care as possible. This includes:

• supporting practices that promote integration into the community;
• creating opportunity for activities with peers in the community (e.g basketball league);
• having an educational component that fosters full development of young people's abilities;
• permitting more open phone privileges, progressively independent access to social media, and visits from friends approved by the family and team;
• ensuring that programming is culturally and linguistically competent and attuned;
• allowing young people to fail safely so as to facilitate learning and growth.

The key to creating such an environment is involving the youth in the conversations regarding what will and won’t be permitted, in a manner in which both youth and adult concerns are heard, understood, and considered in arriving at mutually acceptable decisions.

Youth-Guided Care at the Organizational Level – Moving towards youth-guided care is not simply a matter of taking a series of actions but requires creation of an organizational environment in which staff recognize the realistic limitations of their understanding and power and nurture an appreciation of positive youth culture. Whether or not the youth and families they serve meet the goals for which they came to treatment is ultimately up to the clients; the organization and staff in reality have very little contingent control over the outcomes. Accepting that the youth might understand themselves as well or better than the adults and sharing power toward fulfillment of responsibilities and expectations can create a culture in which youth-guided care can flourish and the difficult work can become more readily accomplished.

Beyond involving youth meaningfully in their own goal-setting and in determining programmatic guidelines, engaging them in organizational processes can also yield transformative changes. Specific practices that can help providers move to being youth-guided include:

• Including youth in staff interviews, with meaningful input into hiring decisions;
• Having youth participate in the training of new staff as both trainers and participants;
• Hiring a peer advocate to help youth understand the “system” and voice their preferences;
• Organizing youth advisory councils or an empowered student government that not only provides input but is empowered to carry out agreed-upon actions to resolve issues;
• Adopting the Youth Bill of Rights (available at www.youthmoveoregon.org)
• Appointing alumni of the program to sit on the agency's Board of Directors.

Taking steps such as these along with those at the care level will enhance organizational climate and performance, and, most importantly, lead to improved outcomes for the youth and families served.
AACRC encourages residential treatment providers to implement policies and practices that will yield further steps toward the transformation to youth-guided care. The AACRC website identifies links to staff training and other resources that can guide and facilitate this process. For more information please access the site at www.aacrc-dc.org or contact AACRC at 877-362-2272